Have healthcare-associated infections increased during the COVID-19 pandemic or not?

The COVID-19 pandemic has enormously increased awareness of the issue of hygiene in politics, as well as among authorities and the general public. Hygienic measures such as hand, surface and instrument disinfection have not only been part of the core components of infection prevention in healthcare facilities since the beginning of the pandemic, but have already been for decades and significantly contribute to reducing healthcare-associated infections (HAI) of all types. However, different sources now suggest that the HAI rate in US and German clinics has increased in the course of the pandemic [1, 2]. But what is the truth and what circumstances could have contributed to it?

Device-associated bacterial infections increased strongly in the US

A recent publication by Weiner-Lastinger et al. points out that with the beginning of the pandemic, particularly the rates of catheter-associated bloodstream and urinary tract infections, ventilation-associated infections and infections with methicillin-resistant S. aureus (MRSA) increased in the US [1]. The article compares 2019 and 2020 using data based on events reported to the National Healthcare Safety Network during that period. For example, in the fourth quarter of 2020 in US acute care hospitals, the rate of catheter-related bloodstream infections increased by 47% and that of ventilation-related infections by 44.8% compared to the previous year [1]. The increase in bacteremia caused by MRSA was also very clear at just over a third [1]. However, the research team emphasises that pandemic-related factors such as longer hospital stays, longer use of medical devices, as well as comorbidities and the greater acuity of patient cases may have influenced this development. In addition, the changed processes and staff shortages could have contributed to the situation. Finally, the authors highlight that American hospitals urgently need to identify gaps in infection prevention and implement infection control programs that can halt or reverse the trend [1].

BARMER Hospital Report 2021 also describes an increase in nosocomial infections in German hospitals

Data on the development of HAI rates during the pandemic were also collected in Germany. For example, the BARMER Institute for Health Research (BARMER Institut für Gesundheitsforschung, bifg) carried out analyses for the BARMER Hospital Report 2021, which are based on the data of around 8.8 million insured persons [2]. It became apparent that the COVID-19 pandemic had obviously thwarted the positive trend of pre-pandemic years with regard to HAI rates. According to the report, the overall HAI rate increased in the first pandemic year 2020 to 6.3% compared to 5.5–5.7% in 2017-2019 – despite approximately 15% fewer hospitalised patient cases [2]. The drop in the number of cases can easily be explained by the pandemic-related allocation of hospital capacities, but the research team cannot find a clear explanation for the increased HAI rates. Similar to Weiner-Lastinger et al., the authors conclude that multifactorial influences such as the particularly vulnerable patient population, but also bottlenecks in protective equipment and the high workload on staff could have influenced the numbers [2].

No increase in device-associated infections in German intensive care units according to the NRZ

However, the data evaluated by the bifg are based on data from insured persons and are of a rather informal nature. In contrast, HAI of various risk areas (e.g. intensive care unit, post-op, neonatal intensive care unit) are officially collected in Germany by the National Reference Center (Nationales Referenzzentrum, NRZ) in the hospital infection surveillance system ‘KISS’ and also in part forwarded to the European Centres for Prevention and Disease Control (ECDC). A research team from the NRZ led by director Prof. Petra Gastmeier has now evaluated and published the data on device-associated HAI for 2020 [3]. Surprisingly, in contrast to the BARMER Hospital Report 2021 and the publication of the American data, no increase in infections is found, but a largely stable situation in German intensive care units is acknowledged [3]. However, the team also draws attention to the fact that the COVID-19 incidence in Germany in 2020 was lower than in the US, that more intensive care beds were available per inhabitant than in other countries, and that the patient mix was different than usual (postponement of elective procedures, etc.) [3].

Focus of hygiene during pandemic different than usual

Overall, data collected at country level are difficult to compare internationally and do not allow hasty general conclusions, such as on insufficient hygiene in certain countries. Differences within a country – as identified between the NRZ and the BIfG – can usually be attributed to differences in the distinction of different risk areas and in data collection. In any case, the full reappraisal of the pandemic years will still take time in many respects and it also remains to be seen how HAI rates will develop in the coming years. It is also conceivable that, especially in the early days of the pandemic, the hygienic focus in clinics was very much on personal protective equipment (masks, gloves, gowns) and less on basic hygiene, i.e. hand and surface hygiene, at times. One thing is certain: In order to implement good hygiene, not only effective high-quality products are required, but they must also be used in everyday life by the hospital staff. Conversely, the risk of HAI obviously increases if the equipment is poor or if the workload on the staff is too high.

Sources:

1. Weiner-Lastinger LM et al. (2022) Infect Control Hosp Epidemiol 43: 12–25. https://doi.org/10.1017/ice.2021.362
2. BARMER (2021) BARMER Hospital Report 2021 [German only]. https://www.bifg.de/publikationen/reporte/krankenhausreport-2021 (accessed on October 12, 2022)
3. Geffers C et al. (2022). Antimicrob Resist Infect Control 11: 67. https://doi.org/10.1186/s13756-022-01108-9